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Clinical Examination Thoracic Spine PDF
Clinical Examination Thoracic Spine PDF
Visceral Musculoskeletal lower aspect of the vertebral body and less behind the
examination examination disc (see online chapter Applied anatomy of the thorax
is negative is positive
and abdomen).
• There is no tendency to spontaneous recovery: in the
lumbar and cervical spines there is usually a spontaneous
cure for root pain, which seldom lasts longer than 4
Orthopaedic lesion
months at the cervical level and 12 months at the lumbar
level. At the thoracic level, no such tendency exists and
constant root pain can persist for many years.
Discodural Non-discal lesion • Protrusions can usually be reduced: although thoracic disc
Discoradicular lesions are more difficult to diagnose, they are easily and
effectively cured. Protrusions – no matter how long they
Fig 25.1 • Routine for differentiation between thoracic and
have been present, or whether they are posterocentral or
abdominal wall pain.
posterolateral, or soft or hard – can usually be reduced by
1–3 sessions of manipulations. Unlike at the lumbar or
fact that posture, physical activity, a deep breath or a cough cervical levels, time is not a criterion for reducibility.
may also influence visceral pain in the thorax or abdomen. Hence a disc displacement may well prove reducible after
The best method of differentiating is to work in two com- constant root pain, even of several years’ standing.
plementary ways: exclusion of any visceral disorder through a Traction is seldom required because the protrusions are
thorough internal check-up, together with positive confirma- usually of the annular type.
tion of a provisional orthopaedic diagnosis (Fig. 25.1). This
routine will also safeguard against unnecessary technical inves-
tigations and delays in diagnosis and treatment.1–3 Non-discal lesions
In the thorax, non-discal musculoskeletal lesions are also
Discal lesions encountered frequently. To name but a few: ribs, rib joints,
cartilage, intercostal and abdominal muscles. This is in contrast
Discodural and discoradicular interactions are well-known
to the cervical and lumbar spines, where lesions of the disc are
causes of cervical and lumbar pain.
the principal cause of dysfunction and pain.
In a discodural lesion, a shifted component of the disc
impinges on the dura and causes pain that has multisegmental
characteristics (crossing the midline and occupying several der-
matomes). Discodural conflicts are characterized by two sets
Referred pain
of symptoms and signs: articular and dural (see Ch. 33).
In a discoradicular lesion, the subluxated disc component Both musculoskeletal and visceral lesions can be the source of
impinges on the nerve root and its dural sleeve. The pain and pain referred to the thoracic and/or abdominal wall.
paraesthesia that result are strictly segmental. Discoradicular
conflicts are characterized by three sets of symptoms and signs:
articular, root and cord.
Pain referred from musculoskeletal
Disc lesions also commonly occur in the thoracic spine but structures
often show characteristics that are quite different from those
found at the lumbar and cervical spines. Dura mater and nerve roots
• The articular signs are subtle: a discodural interaction at Pain originating from the dura mater is referred in a multiseg-
the cervical or lumbar level usually presents with a clear mental way: it crosses the midline and may cover several con-
partial articular pattern: some movements hurt or are secutive dermatomes (see p. 18). A possible explanation for
limited and others do not, always in an asymmetrical way. this phenomenon may lie in its multisegmental origin, which
This is not so in the thoracic spine. Because of the rigidity is reflected in the considerable overlap between the fibres of
of the thorax, such an obvious pattern is seldom found. the consecutive sinuvertebral nerves innervating its anterior
Very often, only one of the six passive movements, usually aspect.4 Recent research has demonstrated that dural pain may
a rotation, is positive and then only slightly so. Therefore spread over eight segments with considerable overlap between
diagnosis in the thoracic spine is more tentative and may adjacent and contralateral dura mater.5 This may be an explana-
have to be based on smaller, subtler abnormalities. tion for the fact that lower cervical discodural conflicts may
• Neurological deficit is seldom encountered in a thoracic produce pain that spreads into the upper thoracic level (Fig.
disc lesion: whereas some degree of neurological deficit is 25.2a) or that lumbar dural pain causes pain in the lower tho-
a common finding in cervical or lumbar posterolateral disc racic region (Fig. 25.2b).
lesions, muscular weakness is rarely detectable in thoracic Pain originating from a nerve root sleeve has a strict segmen-
discoradicular lesions. Also, disturbance of sensation is tal reference and is restricted to the borders of the
very rare. This absence of neurological signs is probably dermatome.
the outcome of the location of the nerve root in the Thoracic disc lesions may thus cause referred pain in the
intervertebral foramen, where it lies mainly behind the thorax, not only as the result of extrasegmental reference in
366
Clinical examination of the thoracic spine C H A P T E R 2 5
367
The Thoracic Spine
T5 T7
T1
T2 T3
T10 T12
368
Clinical examination of the thoracic spine C H A P T E R 2 5
• Intervertebral facet joints: these give rise to unilateral hemidiaphragm are innervated by intercostal nerves. Pain is
paravertebral pain, felt deeply and locally, but not going localized to the cutaneous distribution of those nerves. The
further lateral than the medial edge of the scapula. If phrenic nerve supplies innervations to the central part of each
several joints are affected at the same time, as may be the hemidiaphragm which is a C4 structure, with pain reference
case in ankylosing spondylitis, the pain spreads more in a to the trapezius area.6
craniocaudal direction than mediolaterally; the opposite is
true for a disc protrusion.
The oesophagus
• Costovertebral and costotransverse joints: the pain is felt
unilaterally between the vertebral column and the scapula. Disorders of the oesophagus (T4–T6) usually give rise to pain
• Anterior longitudinal ligament: when this ligament is felt at any part of the sternum, often radiating between the
affected, pain is usually located anteriorly behind the scapulae into the back (Fig. 25.4b).
sternum.
• Posterior longitudinal ligament: involvement of this The diaphragm
ligament causes pain in the back, felt centrally between The central part of the diaphragm is mainly derived from the
the scapulae. third, fourth and sometimes, although rarely, the fifth cervical
• Disorders of the costocoracoid fascia or the trapezoid and segments. Pain from irritation of the central part of the dia-
conoid ligaments (see online chapter Disorders of the inert phragm is felt at the tip of the shoulders and the base of the
structures): the pain is usually felt in the infraclavicular neck. Pain from the peripheral part is felt more locally in the
fossa. lower thorax and in the upper abdomen at the costal margin
(Fig. 25.4c).
Muscular lesions
Muscular sprains of the intercostal muscles, the abdominals The stomach and duodenum
and the muscles of the shoulder girdle usually provoke well- Pain from stomach and duodenum (T6–T10) is most com-
localized pain at the site of the lesion. monly felt in the epigastrium and upper abdomen, sometimes
substernally and exceptionally in the lower thoracic part of the
back (Fig. 25.4d).
Pain referred from visceral structures
The heart The liver, gallbladder and bile ducts
Pain arising from disorders of the heart can be referred to The liver is derived from the right side of T7–T9. The gallblad-
dermatomes C8–T4 because the heart is derived largely from der and bile ducts are of right T6–T10 origin. Pain is felt in
these segments. Therefore pain can radiate towards the tip of the right hypochondrium and may radiate towards the inferior
the shoulder, to the anterior chest and to the corresponding angle of the right scapula (T7–T9) (Fig. 25.4e).
region of the back. It may also be referred towards the ulnar
side of both upper limbs, though referral to the left side is The pancreas
more common (Fig. 25.4a). Pain from the pericardium always
arises from the parietal surface because this is the only part Patients suffering from a pancreatic disorder complain of upper
which has a sensory innervation. abdominal pain often referred to the back at T8 (Fig. 25.4f ).
369
The Thoracic Spine
(g) Kidney–Ovary–Testicles
Fig 25.4 • Pain referred from visceral structures: (a) heart; (b) oesophagus; (c) diaphragm; (d) stomach; (e) gallbladder; (f) pancreas;
(g) kidney/ovary/testicles.
370
Clinical examination of the thoracic spine C H A P T E R 2 5
371
The Thoracic Spine
central posterior thoracic pain that starts after some hours and uncontrollable intraspinal bleeding. The same applies in con-
increases throughout the day, are likely to be suffering from genital or acquired disorders of blood coagulation.
posterior bulging of the whole content of an intervertebral disc
as a consequence of excessive thoracic kyphosis.
Pain felt at the base of the neck is sometimes the result of Inspection and palpation
a problem at the first costovertebral joint, the sternoclavicular
joint or a fracture of the first rib. On inspection, the curvature of the thoracic spine is noted.
Pain at the sternum is seldom the result of a musculoskeletal Scoliosis and hyperkyphosis may be detected.
disorder. Most often it has a visceral origin. The same is true
for pain felt in the abdomen: muscular lesions do exist but are
rare. They usually give rise to well-localized pain.
Scoliosis
A deformity in the frontal plane is named scoliosis. If present,
Is the pain influenced by coughing, sneezing or it is important to determine whether it is located at the lumbar
deep inspiration? or thoracic level. Thoracic scoliosis can often be voluntarily
When a Valsalva manœuvre or a deep breath provokes or corrected by the patient. In this event, it is postural and has
increases the cervical or lumbar pain, it is generally interpreted no specific pathological implications. In structural scoliosis, the
as a dural symptom, from interference with the dura mater by deformity cannot be corrected by muscular activity. There is
a protruded disc or a tumour. In the thoracic area, it is not so often associated shoulder asymmetry too. In this event, the
simple. Many disorders other than problems of the dura may scapula at the convex side is usually more prominent and the
give rise to the same symptom. Deep inspiration may increase arm of this side touches the hip, but the other arm hangs
pain because of one of a number of visceral disorders or other further away from the body.
musculoskeletal problems. Tumours of the respiratory tract,
pleurisy, lung embolism, pneumothorax and even pericarditis Kyphosis
can all give rise to pain increased by coughing or respiration.
The same may be found in non-discal musculoskeletal problems A hyperkyphotic thoracic spine with a flattened lumbar spine
of the ribs and sternum. Fractures and contusions of the ribs, may suggest ankylosing spondylitis. An excessive low thoracic
a sprained intercostal muscle and a fracture of the sternum are and high lumbar kyphosis can be the result of Scheuermann’s
all in the same class. Consequently, the influence of respiration disease or osteoporosis.
on symptoms at the thoracic level is only regarded as a dural Sometimes a localized angular kyphosis is found as the result
symptom once there is clinical certainty of disc protrusion. In of a collapsed vertebral body, usually due to pathological or
thoracic disc protrusions it is more usual for deep inspiration, traumatic fracture or resulting from adolescent osteochondro-
rather than a cough, to exacerbate the symptoms. sis. It is best felt by gliding the fingers over the spinous proc-
esses in a craniocaudal direction. It is more difficult to detect
Paraesthesia at the thorax than elsewhere because of the general kyphotic
shape of the thoracic spine.
Protrusion of a disc in the thoracic region can produce pins and
needles in two ways. First, it may be the result of compression
of the spinal cord, which is characterized by extrasegmental
Functional examination
pins and needles felt in both feet and typically increased or
provoked by flexion of the neck. Cord compression and par- Clinical routine differs significantly according to the level of
aesthesia can also be caused by intra- and extraspinal tumours, the pain (Fig. 25.5). For a number of reasons, pain felt above
intraspinal haemorrhage or a vertebral fracture. Second, par- the T6 level (mid-scapular) demands a preceding clinical
aesthesia can be stem from posterolateral protrusion compress- examination of the cervical spine and the shoulder girdle. First,
ing a nerve root. For example, pins and needles may be felt in the upper two thoracic vertebrae, anatomically belonging to
the groin from compression of the T12 nerve root. In this the thoracic spine but clinically part of the cervical spine, are
event, the features are always localized and limited to the cor- tested in the clinical examination of the cervical spine. Second,
responding dermatome. it was demonstrated previously that cervical discodural inter
Both causes are rare, and when paraesthesia is present, other actions often provoke extrasegmentally referred pain in the
conditions, such as neuropathy due to generalized disorders upper half of the thorax. Third, numerous lesions of the tho-
(diabetes, pernicious anaemia and multiple sclerosis), must racic apex and the shoulder girdle, although causing pain in the
always been considered first. cranial aspect of the thorax, are only detected by proper exam-
ination of the cervical spine and/or the shoulder girdle: a
tumour of the apex of the lung involving the T1 nerve root is
Anticoagulant treatment and only detected by cervical tests; neuritis of the suprascapular
bleeding disorders nerve causes pain in the supraspinatus fossa and is detected by
a combined weakness of supra- and infraspinatus muscles. A
The use of anticoagulants is always an absolute contraindica- fracture of the first rib provokes upper thoracic pain but the
tion to manipulation of the spine, because it can lead to diagnosis can be missed if the examiner proceeds immediately
372
Clinical examination of the thoracic spine C H A P T E R 2 5
with examination of the thoracic spine. For all these reasons, Standing
in patients with upper thoracic pain, a full cervical examination
followed by examination of the shoulder girdle must be done
Dural tests
first. Only when these are negative should a thorough examina-
tion of the thoracic spine follow. It is believed that deep inspiration, neck flexion and some
If the patient has pain below T6, a cervical or shoulder girdle scapular movements may indirectly stretch the dura mater.
problem is unlikely and attention is immediately directed to
Taking a deep breath (Fig. 25.6a)
the thoracic spine.
Functional examination of the thoracic spine consists of a The patient is asked to take a deep breath and to state if the
large set of basic tests. The examination is performed with the pain increases. A positive test is regarded as a dural sign only
patient standing, sitting and lying prone. During the procedure, when, after the rest of the examination is performed, a disc
dural, articular, muscular and cord signs are sought. Some- lesion seems to be present. In such a case, stretching of the
times, when particular symptoms or signs from the basic exam- dura mater via the intercostal nerve roots is interfered with.
ination warrant, the procedure is completed by specific
Flexion of the neck (Fig. 25.6b)
accessory tests.
The patient is asked to bend the head actively forward. This
may increase the pain or provoke paraesthesia.
Thoracic pain In thoracic spine problems, pain during active neck flexion
is basically regarded as a dural sign because flexion stretches
the dura mater from above. However, pain on neck flexion as
Above T6 Below T6 the result of impaired dural mobility does not necessarily mean
a disc lesion is present. Indeed, any kind of intraspinal space-
occupying lesion that interferes with the dura, such as a
Full cervical spine examination Full thoracic spine examination
tumour, may provoke pain on neck flexion. A problem with
+
Shoulder girdle examination one of the posterior ligaments or posterior paravertebral
muscles may also cause pain on neck flexion.
Sometimes a patient feels a sudden sensation on neck
Positive Negative Negative Positive flexion, resembling an electrical discharge going down his back
and occasionally even spreading towards both arms and legs.
Sometimes it also occurs on extension of the neck. This is
Cervical spine or Thoracic/abdominal known as Lhermitte’s sign and was previously regarded as
Visceral disorder?
shoulder girdle lesion wall lesion
pathognomonic for disorders of the cord at the cervical level.
In later reports it has been suggested that problems of the
Fig 25.5 • Examination strategy in thoracic pain. thoracic cord may cause the same sign. This can be caused by
Fig 25.6 • Dural tests at the thoracic level: (a) taking a deep breath; (b) flexion of the neck; (c) backward movement of the scapulae.
373
The Thoracic Spine
multiple sclerosis, a tumour of the cord, disc lesions, tubercu- rotations, together with a larger limitation of extension and
losis, spondylosis, arachnoiditis or radiation myelopathy.8 little or no limitation of anteflexion (Fig. 25.8). It resembles
Neck flexion may also provoke or increase pins and needles. the pattern for the cervical spine. If this is found, a disorder
If these are felt in one or both lower limbs, this draws attention of the entire segment of motion, such as in ankylosing spondyl
to compression of the spinal cord at the thoracic level, which itis or osteoarthrosis, is present.
is most commonly the result of a disc lesion or a tumour. Any other combination of abnormal tests is regarded as a
partial articular pattern (Fig. 25.9). Such a combination could
Shoulder movements: upwards, forwards be, for instance, pain on one rotation or one side flexion
and backwards together with one rotation, or one side flexion and extension,
The patient is now asked to shrug both shoulders and to bring or three, four or five of the six movements being positive in
them forwards and backwards. producing pain or limitation. As long as abnormal tests are
These tests are basically active movements of the structures present in a non-symmetrical way, the pattern is regarded as
of the shoulder girdle. Therefore some will be positive when being partial articular.
a disorder of one of those structures is present (see online In all types of disc lesion a partial articular pattern is
chapter Applied anatomy of the shoulder girdle). expected. In the thoracic spine, a common finding is that only
However, if one or all of these movements elicits pain, it is one out of the six articular movements is positive – usually one
most frequently the result of a thoracic disc lesion, because of the rotations. Differentiation must always be made from a
they all (to a greater or lesser degree) stretch the dura mater facet joint lesion or a muscular lesion, in which a partial articu-
at the thoracic level, which is elongated in a cranial direction lar pattern is also found. In the latter, some of the resisted
via the T1 and T2 nerve roots (Cyriax9: p. 202). The most movements are more painful.
sensitive test is scapular approximation (shoulders backwards,
Fig. 25.6c).
Warning
Active trunk movements
The patient is now asked to perform six active movements of When side flexion away from the painful side (Fig. 25.10) is the
the trunk. These involve both the thoracic and the lumbar only painful and limited movement, this always indicates a severe
spine. Differentiation is made by the level of the pain, as indi- extra-articular lesion such as a pulmonary or abdominal tumour or
cated by the patient, and on extension pressure at the end of a spinal neurofibroma.
the examination.
On flexion, extension and side flexion to both sides the
range of movement is greatest in the lumbar spine, rather than
the thorax. Rotation movements, in contrast, occur only slightly Sitting
at the lumbar level and involve mostly the thoracic spine.
The movements performed are: The examination is now continued by looking at passive and
resisted rotations to both sides, with the patient sitting. In the
• Anteflexion (Fig. 25.7a)
seated position Babinski’s reflex is also elicited.
• Extension (Fig. 25.7b)
• Left side flexion (Fig. 25.7c)
Passive tests
• Right side flexion (Fig. 25.7d)
• Left rotation (Fig. 25.7e) • Passive left rotation (Fig. 25.11a)
• Right rotation (Fig. 25.7f). • Passive right rotation (Fig. 25.11b).
The patient performs these movements actively. Pain and limi- The patient crosses both arms in front of the chest. The knees
tation are noted. In structural scoliosis the associated hump are held between the examiner’s legs to immobilize the pelvis.
persists and is accentuated on forward bending. The patient’s trunk is now twisted towards the left and the
While performing rotations, the patient keeps the head in right by the examiner. Pain, range of movement and end-feel
neutral position in relation to the shoulders, to avoid cervical are noted.
rotation. The normal end-feel is elastic. A hard end-feel is typical of
ankylosing spondylitis or advanced arthrosis. Both an empty
Conclusions from active trunk movements end-feel and muscle spasm suggest a severe disorder: neo-
In principle, the six movements described so far are articular. plasm, fracture and infectious disorders.
However, because they are performed actively, they involve Rarely, pain is present at half range, disappearing when rota-
some contractile structures as well. Passive and resisted move- tion continues. This is known as a painful arc and was regarded
ments (see below) provide the key in differential diagnosis by Cyriax9 as pathognomonic for a disc lesion when combined
between inert and contractile structures. After these tests, the with a partial articular pattern.
examiner should know whether an articular pattern is present At the end of both passive rotations the patient is asked to
or not. bend the head actively forwards. If this movement further
The articular pattern of the thoracic spine is an equal degree increases the pain, it is regarded as a dural sign if the rest of
of pain and limitation of both side flexions and of both the examination suggests that a disc lesion is present.
374
Clinical examination of the thoracic spine C H A P T E R 2 5
Fig 25.7 • Active trunk movements: (a) anteflexion; (b) extension; (c) left side flexion; (d) right side flexion; (e) left rotation; (f) right rotation.
375
The Thoracic Spine
Fig 25.10 • Pain and limitation on side flexion away from the painful
Fig 25.8 • The full articular pattern.
(coloured) side is a warning sign for serious disorders.
Lying prone
Location of affected level by passive .
extension thrust
The patient lies prone and a hyperextension thrust is given over
every thoracic spinous process to locate the painful level. To
do this, the hand is placed obliquely, with the fifth metacarpal
bone on the spinous process (Fig. 25.14). Identification of the
exact level is important, because some manipulations for tho-
racic disc protrusions are performed specifically at the level
at fault.
During extension pressure, attention is also paid to the type
of end-feel. Normally it is elastic. Muscle spasm is a warning
of more severe disorders.
Accessory tests
To reach a diagnosis, the basic clinical examination normally
suffices. In circumstances that remain unclear or when a mus-
cular problem is suspected, accessory movements must be
carried out.
376
Clinical examination of the thoracic spine C H A P T E R 2 5
(a) (b)
Fig 25.11 • Passive rotation: (a) left; (b) right. At the end of each movement the patient is asked to bend the head forwards.
(a) (b)
377
The Thoracic Spine
378
Clinical examination of the thoracic spine C H A P T E R 2 5
Testing the long thoracic nerve exactly on the suspected rib. The other hand rests with the
pisiform bone on the contralateral transverse process of the
The patient pushes against a wall with the arms stretched out
corresponding vertebra (Fig. 25.20). Oscillations are now
horizontally in front (Fig. 25.19). If the medial edge of the
given by the hand resting on the rib. At the same time, the
scapula moves away from the thorax to produce a winged
other hand is used to prevent rotation of the vertebra by
appearance, a disorder of the long thoracic nerve is present.
pressing simultaneously on the transverse process. These oscil-
lations influence mainly the costovertebral and costotransverse
Oscillation of a rib joints. When there is inflammation, pain will be provoked;
The examiner stands on the pain-free side and places one when ankylosing spondylitis is present, the movement will be
hand distally on the thorax, with the fifth metacarpal bone less elastic.
Fig 25.15 • Stretching the T1 nerve root. Fig 25.17 • Resisted flexion.
(a) (b)
379
The Thoracic Spine
(a)
Neurological examination
A full neurological examination must be carried out when
compression of the spinal cord or a neurological disorder is
suspected.
The following accessory tests should be performed.
Beevor’s sign
The patient lies supine, crosses the arms in front of the chest
and is asked to raise the trunk slightly off the couch. The
examiner pays attention to the umbilicus, which should not
move during this test. Any movement in a cranial or caudal
(b)
direction or to the side may point towards a denervation of the
contralateral muscles.
Oppenheim’s sign
This may confirm a positive Babinski’s sign. When the fingers
are slid downwards along the tibia, no movement of the toes
should occur. In cord compression, the big toe extends while
the others spread. However, this test is less reliable than a
(c)
Babinski’s sign.
Palpation
Fig 25.18 • Extension of the trunk is performed in three different If a muscular lesion is suspected, the affected structure should
ways: (a) resisted; (b) active; (c) passive. be palpated.
380
Clinical examination of the thoracic spine C H A P T E R 2 5
Reflexes
Patellar reflex L3
1 Achilles tendon reflex S1
Sensitivity
Temperature
Numbness
381
The Thoracic Spine
Box 25.2
herniated discs. After comparing the imaging characteristics symptoms. The diagnosis ‘symptomatic thoracic disc lesion’ is
with a series of five symptomatic thoracic herniated discs, the therefore primarily a clinical one.
authors were unable to identify any features that could reliably
classify a herniated disc as asymptomatic or symptomatic.17
All these studies clearly demonstrate that thoracic disc Access the complete reference list online at
herniations shown by MRI may not be related to patients’ www.orthopaedicmedicineonline.com
382
Clinical examination of the thoracic spine CHAPTER 14
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